The nurse is caring for a client who is being discharged following coronary artery bypass graft surgery. Discharge instructions would include:

A) Encouraging the client to cough and deep breathe every two hours:
Encouraging the client to cough and deep breathe is an important nursing intervention for clients with a chest tube. This helps promote lung expansion, prevent atelectasis, and improve respiratory function. It also helps to clear secretions that may accumulate in the lungs. Therefore, this practice is appropriate and beneficial for the client.

B) Stripping the chest tube to dislodge any blood clots:
Stripping the chest tube, which involves forcibly pulling or pinching the tubing to remove clots, is an unsafe and outdated practice. It can create a dangerous increase in intrathoracic pressure, which may lead to tension pneumothorax, as well as injury to the lung tissue. Instead, the nurse should focus on gently milking the chest tube if necessary (if prescribed by the healthcare provider) or ensure that any blood clots are properly managed by the physician. Stripping or clamping the tube without proper indications is contraindicated.

C) Assessing the client's respiratory status frequently:
Frequent assessment of the client's respiratory status is crucial when managing a patient with a chest tube. The nurse should monitor for signs of respiratory distress, changes in breath sounds, oxygen saturation, and any signs of complications such as pneumothorax or hemothorax. Regular respiratory assessment helps in early detection of issues and provides the data necessary to manage the client's care effectively.

D) Monitoring skin for subcutaneous emphysema:
Monitoring for subcutaneous emphysema is a vital part of nursing care for a client with a chest tube. Subcutaneous emphysema occurs when air escapes from the pleural space into the tissues under the skin, and can be a sign of a pneumothorax or a complication related to the chest tube. It is important to detect this early so appropriate intervention can be made to prevent further complications.

A. Guidewire-induced dysrhythmia: Guidewire-induced dysrhythmia can occur if the guidewire or catheter irritates the heart during insertion, particularly when the catheter is placed in the central venous system. While this can lead to arrhythmias, it is typically more immediate and occurs during the procedure itself. The symptoms of dysrhythmia (e.g., irregular heartbeat) would more likely present right after insertion or during the manipulation of the guidewire. The signs of restlessness, JVD, and tachycardia observed 30 minutes after placement are more suggestive of a pneumothorax than of a guidewire-induced dysrhythmia.

B. Pneumothorax: Pneumothorax is a potential complication of central venous catheter (CVC) placement, particularly when the catheter is inserted into the subclavian vein. The right subclavian vein is located near the apex of the lung, so inadvertent puncture of the lung during catheter placement can lead to air entering the pleural space, causing a pneumothorax. The symptoms of pneumothorax may include restlessness, tachycardia, jugular vein distention (JVD), and respiratory distress. A heart rate of 120 beats per minute is consistent with tachycardia due to hypoxia or distress, and JVD can be a sign of increased intrathoracic pressure or impaired venous return, which occurs with a pneumothorax. These symptoms warrant immediate assessment for pneumothorax, which can be confirmed with a chest x-ray.

C. Pulmonary infarction: Pulmonary infarction occurs when a blockage in the pulmonary arteries prevents blood flow to lung tissue, resulting in tissue death. This can be caused by a pulmonary embolism or other issues, but it is not a typical complication of central venous catheter placement. The symptoms described (restlessness, JVD, and tachycardia) are more consistent with a pneumothorax than a pulmonary infarction, which would likely cause chest pain, hemoptysis, or dyspnea rather than these signs.

D. Venous thrombosis: While venous thrombosis (or clot formation) is a potential complication of central venous catheter placement, it typically manifests as swelling, redness, or pain at the catheter insertion site, rather than with the systemic symptoms of restlessness, tachycardia, and JVD. Venous thrombosis could cause some of the described symptoms in the long term, but it is less likely to be the cause of acute symptoms 30 minutes post-procedure. The immediate concern in this case is more likely to be pneumothorax, which can occur more suddenly and cause these symptoms.Top of FormBottom of Form